Lina Matta

Intravenous Diuretic Therapy for the Management of Heart Failure and Volume Overload in a Multidisciplinary Outpatient Unit

OBJECTIVES This study sought to evaluate the effectiveness of intravenous (IV) diuretic treatment for volume management in heart failure (HF). BACKGROUND Limited data exist regarding IV diuretics for the outpatient treatment of volume overload in HF patients. METHODS We analyzed 60 consecutive patients with chronic HF and clinical evidence of worsening congestion who received a bolus and 3-h IV infusion of furosemide at an outpatient HF clinic. Diuretic dosing was derived from the maintenance oral loop diuretic dose with a standardized conversion algorithm. Outcomes included urine output during the visit, weight loss at 24 h, and hospitalization and mortality at 30 days. Safety outcomes included hypokalemia and worsening of renal function. Outcomes were analyzed across subgroups defined by maintenance diuretic dose and ejection fraction (EF). RESULTS The median age of the cohort was 70 years (interquartile range [IQR]: 58 to 80 years), and the median daily loop diuretic dose was 240 mg (IQR: 80 to 800 mg) oral furosemide or equivalent. Twenty-six patients (43.3%) were women, and 36 (60%) had an EF ≤45%. For the entire cohort, the median urine output and 24-h weight loss were 1.1 l (IQR: 0.6 to 1.4 l) and 1.1 kg (IQR: 0.2 to 1.9 kg), respectively. Outcomes were similar across patients with varying maintenance diuretic doses (<40 mg, 40 to 160 mg, 160 to 300 mg, or >300 mg of furosemide or equivalent) and in patients with reduced or preserved EF. Transient worsening of renal function and hypokalemia occurred in 10 patients (8.9%) and 4 patients (3.5%). Although hospitalization was reported as imminent for 28 patients (52.8%), the observed rate of all-cause hospitalization was 31.7% at 30 days with no deaths. CONCLUSIONS Short courses of IV diuretics for volume management in patients with HF were safe and associated with significant urine output and weight loss across a wide range of maintenance diuretic doses and EF. This strategy may provide an alternative to hospitalization for the management of selected HF patients.

Evaluation of a clinical pathway for sedation and analgesia of mechanically ventilated patients in a cardiac intensive care unit (CICU): The Brigham and Women's Hospital Levine CICU sedation pathways

Background: Intravenous sedation and analgesia are important therapies during mechanical ventilation (MV). However, daily interruption of these medications is associated with improved outcomes in mechanically ventilated patients. We tested a clinical pathway for the use of sedation and analgesia during MV in a cardiac intensive care unit (CICU). Methods and results: We evaluated all mechanically ventilated patients in a CICU during two phases: phase 1 prior to pathway implementation (PRE) and phase 2 post-pathway implementation (POST). A total of 198 patients (98 PRE and 100 POST) and 1012 days of intubation (574 PRE and 434 POST) were included in this analysis. We found an increase in the frequency of daily interruptions of sedation post-implementation (49.3% PRE and 58.4% POST, p=0.0041). There was a significant decrease in the mean duration of MV in the POST vs PRE periods (5.0±2.3 vs 6.1±2.8 days, p=0.015). There was also a significant decrease in total neuroimaging studies (9 vs 49, p=0.001) and a trend toward a decrease in tracheostomies (3.0% vs 6.1%, p=0.33). Mean CICU length of stay (LOS) and hospital LOS respectively were 10.4 days and 16.8 days PRE and 10.4 days and 17.9 days POST (p=0.99 and p=0.55). Mortality did not differ (PRE 36.7% vs POST 32.0% p=0.55). Conclusions: Implementation of a pragmatic pathway for sedation and analgesia in a CICU was associated with an increase in the daily interruption of sedation and a corresponding decrease in the duration of MV days and the need for neuroimaging.

Impact of an Immunoglobulin G–Specific Enzyme‐Linked Immunosorbent Assay on the Management of Heparin‐Induced Thrombocytopenia

To evaluate whether using an immunoglobulin G (IgG)‐specific platelet factor 4 (PF4) test reduces the rate of positive PF4 results and has an impact on prescribing practices of nonheparin anticoagulants (direct thrombin inhibitors and fondaparinux) in patients assessed for heparin‐induced thrombocytopenia (HIT).

Assessment of Drug Therapy-Related Issues in an Outpatient Heart Failure Population and the Potential Impact of Pharmacist-Driven Intervention:

Background: The Ambulatory Cardiac Triage, Intervention, and Education (ACTIVE) infusion unit is an outpatient center that aims to provide heart failure (HF) patients with comprehensive multidisciplinary interventions. Objective: To describe the patient population served in ACTIVE and to document the prevalence of comorbidities and drug therapy-related issues (DRIs) in order to define the most effective role of a pharmacist in the unit. Methods: Patients who have been interviewed by a pharmacist in ACTIVE were included. Comprehensive medical and medication profile reviews were performed. Patient comorbidities were documented, and DRIs were classified. Results: Sixty patients were included. Most prevalent cardiac comorbidities included hypertension (73%) and hyperlipidemia (62%). Top 3 noncardiac comorbidities included chronic kidney disease (60%), diabetes (50%), and obesity (35%). The prevalence of DRI was reported as follows: (1) needs additional/alternative therapy (untreated indication [37] or suboptimal therapeutic choice [46]), (2) wrong drug (major drug–drug interaction [90], contraindication [11], or duplicate therapy [1]), (3) suboptimal dosing (17), (4) dose exceeds recommended maximum (9), and (5) adverse drug reaction (93). In 63 (22%) of the DRIs, a pharmacist made recommendations to modify the regimen. Conclusion: The prevalence of DRI is high even among HF patients managed in a subspecialty cardiovascular practice. Pharmacists in this setting play a vital role in more effectively resolving DRI.

Evaluation of a multi-target direct thrombin inhibitor dosing and titration guideline for patients with suspected heparin-induced thrombocytopenia

To the Editor: Heparin-induced thrombocytopenia (HIT) is an antibody-mediated adverse drug reaction that can occur in patients receiving heparinoid therapy [1,2]. Management of HIT consists of discontinuation of the heparinoid and anticoagulation using a direct thrombin inhibitor (DTI), such as argatroban and bivalirudin. Institutions have implemented dosing guidelines for initial DTI dosing and titration. Standardization of DTI dosing and titration using a nursing driven guideline titrating to an activated partial thromboplastin time (aPTT) goal of 50–80 has been shown to reduce time and number of titrations to therapeutic aPTT [3]. An analysis of two dosing guidelines for argatroban achieved an aPTT goal of 50–70 [4]. To our knowledge, currently no published bivalirudin dosing guideline exists that allows for a more stringent aPTT goal. Brigham and Women’s Hospital instituted a dosing and titration guideline for argatroban and bivalirudin that allowed the prescriber to select between three therapeutic aPTT goals: 50–80, 50–70, or 60–80 (Table 1). The protocol provided guidance for agent selection and dosing strategy based on age, organ function, and clinical condition. We hypothesized that a standardized dosing and titration guideline for DTIs improve achievement of therapeutic goals in patients with proven or suspected HIT. We conducted a single center, prospective, observational evaluation of patients treated with a DTI according to a dosing and titration guideline compared to a historic control

Pharmacy Response to the Boston Marathon Bombings at a Tertiary Academic Medical Center

Objective: Effective crisis response requires multidisciplinary communication and rapid action. Our goals are to highlight the experience of a pharmacy department’s response to the 2013 Boston Marathon bombing, to discuss the role of the pharmacist in a crisis response, and to identify potential learning opportunities for a future mass casualty event. Case Summary: Our initial response targeted 3 general areas: staffing, supplies, and communication. Pharmacist and technician staffing was increased throughout the hospital, with a 6-fold increase of pharmacists to the emergency department (ED). To ensure adequate supplies were available, inventory on the ED automatic dispensing cabinets (ADC) was assessed for vaccines, antibiotics, and vasoactive medications. ED pharmacists prepared emergent intravenous medications in the ED while the sterile products room bolstered our supply of intravenous medications for patients in the ED and operating room. Overall, there was a 33% increase in the number of ADC transactions, with pharmacists representing 28% of all ADC transactions. To optimize communication, we formulated a comprehensive plan for the timely dissemination of information to the entire pharmacy staff. Discussion: A mass casualty event is a rare occasion, and it is vital for the pharmacy department to respond rapidly with little notification. Conclusion: The role of a pharmacist is unique and can most effectively triage drug information and medication distribution, especially during times of high demand and high stress.

Evaluation of a transitional care pharmacist intervention in a high-risk cardiovascular patient population

Purpose. The utility of a transitions‐of‐care (TOC) pharmacist intervention focused on improving the quality and safety of the medication process for high‐risk cardiovascular patients was evaluated. Methods. A quality‐improvement initiative was developed for patients with heart failure or acute coronary syndrome followed longitudinally at a hospital’s outpatient cardiovascular clinic. The TOC pharmacist intervention occurred either before a patient’s outpatient cardiovascular clinic appointment or during a hospitalization. The major outcome analyzed was the number of unplanned hospital readmissions within 30 days. Additional endpoints evaluated included the time to healthcare utilization, number of medication discrepancies identified, percentage of therapeutic recommendations accepted by a provider, number of medication access issues resolved, patient cost savings, patient satisfaction, and mean time spent on an intervention by the pharmacist per patient encounter. Results. A total of 118 patients received the TOC pharmacist intervention. A total of 516 medication discrepancies were identified and corrected, with 55.6% of discrepancies involving cardiovascular medications. A total of 244 recommendations for therapeutic optimization were provided, with an 81% provider acceptance rate and a 100% patient satisfaction rate. Fifty‐five patients were provided with medication cost savings, and medication‐access issues were resolved for 8 patients. A TOC pharmacist spent means of 98 and 73 minutes on patient education and coordination of care during inpatient and ambulatory encounters, respectively. The 30‐day hospital readmission rate for patients with heart failure was reduced by 20%. Conclusion. A TOC pharmacist intervention improved the quality and safety of care across both inpatient and ambulatory settings for high‐risk cardiovascular patients at our institution.

Potassium Chloride Sustained Release Dosing Pathway in an Academic Medical Center

Potassium supplementation can be administered intravenously or orally with either immediate release or sustained release formulations. Sustained release potassium chloride allows for delayed absorption and peak effects. In the inpatient setting, it is important to monitor and prevent both hypokalemia and hyperkalemia. Our tertiary-care academic hospital created a clinical pathway for sustained release potassium chloride supplementation in the inpatient population. Our clinical pathway for sustained release potassium chloride creates dosing restrictions designed to prevent hyperkalemia, while allowing exceptions for patients with high requirements.

Letter to the Editor - Fixed Dose Intravenous Insulin Protocol

FIXED DOSE INTRAVENOUS INSULIN PROTOCOL We read with concern the opinion by Dr. Dickerson supporting a nonvalidated ‘‘fixed’’ dose intravenous insulin protocol (IIP). First, we would like to point out that fixed dose IIPs have inherent flaws; they do not adjust insulin rates based off of glycemic fluctuations and do not take into account the current insulin rate. Second, it is important to note that published support of any protocol should be tempered in the absence of actual metric assessment. Such endpoints could include, but are not limited to, baseline characteristics, mean glucose levels, time to target attainment of goal glucose, incidence of hypoglycemia per patient, incidence of hypoglycemia per glucose value, time weighted glucose, and protocol compliance. Third, Dr. Dickerson specifically mentioned our reported rate of protocol violation without mentioning his institution’s rate of compliance. Given the lack of disclosed compliance data, the author cannot speculate that one institution has better or worse compliance over another’s published compliance rates. As a point of fact, there are other similar fixed dose IIPs that have demonstrated similar compliance rates to our protocol. We highlighted this relationship in our article in the following statement: ‘‘Despite the potential calculation difficulties and complexity of a multiplication factor protocol, our data suggest that the number of calculation deviations is similar to that of fixed-dose protocols.’’ We support the American Association of Clinical Endocrinologists (AACE) and American Diabetes Association’s (ADA) recent consensus statement supporting ‘‘validated written or computerized protocols that allow for predefined adjustments in the insulin infusion rate based on glycemic fluctuations and insulin dose.’’ Fixed dose IIPs fail to adjust the dose of insulin based off of important therapeutic principles, such as glycemic fluctuation and insulin dose, which are both considered to be important clinical guides in appropriate management. To illustrate this point, the fixed dose IIP in the review states there should be ‘‘no change’’ in the insulin rate if the glucose value is between 101 to 125 mg/dL. If the previous glucose was 200 mg/dL and the next hour’s check is 105 mg/dL (a rate of change of 95 mg/dL), the insulin infusion rate would inexplicably have ‘‘no change.’’ Because the rate of change or glycemic fluctuation is not accounted for in fixed dose IIP, we believe that this type of protocol is dangerous and does not meet the expectations of AACE and ADA. Dr. Dickerson mentioned a ‘‘confusing table’’ as the reason for the compliance rates with our institution’s IIP, however, he failed to mention that even with the relatively high rate of protocol violations our critical care nurses managed to titrate the insulin well enough to achieve acceptable glucometrics including a low incidence of hypoglycemia. Software IIP utilizing multiplication factor adjustments based on glycemic fluctuation and current rate of insulin with reminders for glucose monitoring should be viewed as the gold standard. In the absence of having the software IIP, we support multiplication factor protocols if they are validated with relevant metrics and continuous quality assessment and improvement strategies, including protocol modifications as necessary and timely feedback to the end users.